INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Brighter Visions Counseling was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility's fire drill records were reviewed on January 31, 2017. The fire drill records indicated that fire drills were conducted on 10/7/16, 11/15/16, 12/16/16, and 1/10/17. The fire drill records did not specify the exit route used during each fire drill.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The procedure for fire drills shall stipulate the exit route used from the office for each monthly fire drill. There four possible exits and these will be rotated in cycle to assure that each route is assessed for efficacy. This procedural correction took effect on February 5, 2017. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Three client records were reviewed on January 31, 2017. The facility failed to document verification that a copy of the consent to release information form was offered to the client in client record # 1.
Client # 1 was admitted into treatment on 11/22/16 and was still active in treatment. A consent to release information to an insurance company, signed and dated on 11/22/16, was documented in the client's record. The facility failed to document verification that a copy of the consent form was offered to the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The form for consent to release information has been amended to include a line for clients to indicate their desire to have a copy of the form for their records. This will be pointed out to each client and explained if necessary. If the client requests a copy it will be provided. The implementation of this procedure takes place immediately. It is the Director's responsibility to train counselors as to the importance of this step, and the compliance with this training is now a part of clinical supervision and review of records. The specific client record, client # 1, has been modified to reflect this plan of correction. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Three client records were reviewed on January 31, 2017. The facility failed to document a treatment plan update at least every 60 days in client record # 1.
Client # 1 was admitted into treatment on 11/22/16 and was still active in treatment. A comprehensive treatment plan was completed for the client on 11/22/16. A treatment plan update was due to be completed for the client by 1/22/16, and one was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment plan updates will be completed within 60 days. In the event of a missed appointment, a case note will document the client's progress and explain the absence and inability to complete an amended iteration the plan by the deadline. This plan of correction to correct the record of client # 1 has been completed by the Director. The Director is in charge of this correction and will include this procedural correction in training of counselors and in weekly supervision meetings in review of records. The facility is in compliance as of February 12, 2017. |